Caring for transgender people: looking beyond the hype

Our world is rapidly changing, and with rapid change comes friction and heated debates between the defenders of the status quo and their challengers. Nowhere is this more noticeable than in the current discussions around gender identity. It is unfortunate that healthy discussions over these complex issues are rare, and are rather marred by hype and sensational news. As humans, we are prone to confirmation biases and extreme views may push us away from considering the evidence at hand. There is a clear need to objectively examine the growing body of scientific evidence. In this special issue of Sexual Health, we aim to look beyond the hype and present a body of research related to transgender health. Besides scrutinising the available data, we must not forget the individuals behind the numbers on the page, who are trying to cope with feelings that may be causing them great distress.

Gender identity is important to who we are. In recent times, a clash of worldviews has stemmed from challenging the traditional gender categories of male and female, with a fluid, non-binary gender identity. One’s gender assignment has traditionally been based on chromosomes and genital anatomy. However, there are some whose inner sense of gender does not match their outward appearance. The term ‘transgender’ is an umbrella term that covers this breadth of experiences of gender expression. Transgender individuals often describe being ‘trapped in the wrong body’ and feel a psychological alienation from their own body. This feeling is not transient and is associated with ongoing distress. In a world that struggles to accept them, their journey in life is often marked by loneliness and shame. The science of gender identity is not yet fully understood and cannot be simply reduced to saying that transgenderism is a ‘lifestyle choice’ – it is much more complex than that.

As we tread into unfamiliar territory, we may find ourselves ill-equipped to deal with the complexities of health care for transgender individuals. One guiding principle, no matter which side of the fence a person sits on this issue, is that all human beings are born free and equal in dignity and rights.¹ We should exercise compassion for those who do not fit into the boxes society has prescribed. Although we should treat everyone the same, transgender people have their own unique healthcare needs. This collection of research is not exhaustive and we confine ourselves to issues that we deem particularly challenging.

First, the heated discussion of appropriate sex education in schools. Schools should be an inclusive place of learning, free from discrimination for students who come from a rich diversity of sociocultural backgrounds. It is estimated that 0.4% of the adult US population are transgender,² with no accurate estimates among school-aged children.³ There is also published evidence, albeit from small sample sizes, reporting that transgender students might face higher discrimination and poorer educational outcomes compared with their counterparts.⁴ Jones presents an update on the need for greater educational and social support for transgender students using the Australian experience as an example.⁴ She reports that while legislation is in place in some states of Australia, translating this into reality is still lagging. The complexities of appropriately translating legislation into school policies and practice are highlighted by Parkinson.⁵ Concern was raised regarding the need to discuss the transitory and fluctuating nature of many adolescents’ questioning and exploration of many aspects of life, including their gender identity and sexual orientation. He cautions against creating an environment where adolescents may be potentially confused rather than helped by the form of sex education proposed. This is consistent with current literature showing that the stability over time of self-reported transgender identity in non-clinic-based populations remains unknown.³ While the debates continue on how best to educate and protect students, there are common grounds from which we can work. First, it is clear that there should not be any bullying or discrimination as a result of one’s gender identity. Second, tactful discussions that do not prematurely label adolescents inappropriately are needed. Open discussions about gender identity is healthy and should be age-appropriate, done with sensitivity, accuracy and based on sound science.

The second issue involves arriving at a ‘true prevalence and incidence’ of transgender individuals. Zucker provides guidance on this issue by reviewing existing epidemiological and quasi-epidemiological research.³ In particular, he focuses on estimating the prevalence and incidence of transgender children and adolescents. He highlights the need to clearly define the boundaries of a ‘case’. Depending on how broad (e.g. studies using self-reported measures) or narrow (e.g. fulfilling DSM-V criteria), the case definition can markedly inflate or underestimate the ‘true prevalence’ of transgender individuals. To date, estimates of prevalence and incidence for transgenderism from children and adolescents remain difficult to attain due to limited data, and of the limited data, none have carefully and consistently defined a ‘case’. This has led to wide ranges of prevalence estimates used in debates from ‘rare’ to 4% of children identifying as transgender. There is a clear need for further research to obtain unbiased samples and determine how best to accurately define transgender individuals.

Third, the diagnosis of transgender children (i.e. below the age of puberty) has been controversial. Winter provides insights into the World Health Organization’s revision of the International Classification of Diseases and related health problems manual (ICD-11) and provides compelling arguments against inclusion of the diagnosis of gender incongruence of childhood.⁶ The concern is that it may pathologise a normal developmental phase of exploration and expression of gender identity. This has important implications for labelling gender-diverse children. He advocates a way forward using Z-codes, a method for coding the reason of encounter if no underlying psychopathology or mental disorder is diagnosed.

Fourth, the legal status of transgender individuals varies across countries. This affects their engagement with the legal system, especially in relation to the criminal law. Green provides a summary of the common legal issues facing transgender individuals: identity recognition, family law and legal recognition of relationships, and dealing with discrimination and violence.⁷

Finally, there are several pragmatic healthcare issues included in this collection to upskill health professionals who care for transgender individuals. Riley discusses the use of a 1-min tool (the Gender Feeling Amplitude) to help assess the level of distress of adolescents who express concerns about their gender identity.⁸ Although the tool is not diagnostic, it may be a useful means to initiate the conversation about gender identity among adolescence. Cornelisse et al. discuss the long-term care of the neovagina.⁹ He covers areas such as how to do a physical examination of the neovagina, management of neovaginal stenosis, hair, prolapse, perforation and fistulation, lower urinary tract problems, sexual function, dealing with discharge/bleeding from a neovagina, STIs and cancer screening. Albeit from a small evidence base, practical recommendations are offered.

McNulty and Bourne,¹⁰ and MacCarthy et al.¹¹ remind us of the high prevalence of HIV and STIs in transgender individuals. Similar to the difficulties in estimating the prevalence of transgender children, the current research on HIV prevalence in transgender people is limited by sample biases and how to adequately define the population. MacCarthy et al. provides a way forward by highlighting the current methodological issues and research gaps in transgender people, especially for studies reporting HIV–STI co-infections and its drivers. It is clear that increased vulnerabilities through the lack of legal and social recognition puts transgender people at higher risk for HIV and STIs, particularly in low- and middle-income countries. Kalichman et al. reminds us of unacceptable disparities among transgender women compared with their cisgender counterparts in every step of the HIV treatment cascade.¹² They contribute to the literature by showing that the lack of tangible support (i.e. having people in one’s social sphere available to help when needed) may account for the health disparities reported, and further strategies are needed for increasing socially supportive interventions.

It is not all grim news. One potential solution to ‘close the gap’ for transgender individuals is to improve their access to comprehensive multidisciplinary health services. Aitken discusses the role of engaging primary care providers, as specialised gender clinics alone cannot address all their health needs.¹³ Primary care providers are ideally placed to facilitate care needed, ranging from mental health conditions, to sexual health, substance abuse, cardiovascular disease due to hormonal treatments, and cancer screening. Rather than creating ‘new’ services targeting transgender people, building upon current health infrastructure by making practices more transgender friendly is a sensible way forward.

This special issue has been called to make us think constructively about the people, not just the label they wear. It highlights the current controversies, but is also a call to action if we are to close the gap on health disparities reported for transgender people. Although there may be views presented that you may not agree with, we hope this collection of articles will stimulate further discussions so that you continue to think critically, constructively and compassionately about transgender people and the issues they face.

The authors declare no conflicts of interest.